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De La Salle Health Sciences InstituteDe La Salle University Medical CenterCollege of MedicineDepartment of Otorhinolaryngology-Head andNeck Surgery
OPD CLINICAL CASEDISCUSSION
August 16-22, 2011
Bryan Paul G. Ramirez
 Junior Intern
Dr. Brendan R. Ferrolino
Preceptor 
 
De La Salle University Medical CenterCollege of MedicineDepartment of Otorhinolaryngology – Head and Neck SurgerySUBMITTED BY: JI BRYAN PAUL RAMIREZPRECEPTOR: DR. BRENDAN R. FERROLINOOPD CLINICAL CASE DISCUSSION (AUGUST 16-22, 2011)1. Miranda, Jian Khurt 6 mo./M
 This is the case of J.M, 6 months old male who came in for follow up and was lastseen Aug. 12, 2011, with a chief complaint of Right Lateral Neck Mass, beneath the post-auricular area.4 months prior to consult, the mother noticed bluish-purple patch beneath thepatient’s right posterior auricular area around the size of 1 peso coin. There were no eardischarge, fever, bleeding, cough and colds. The patient was seen and examined by ENTOPD last 7/14/2011 and was diagnosed with reactive lymphadenitis r/o hemangioma. He wasprescribed with Clindamycin 75/5ml 1.25 ml q6 x 7 d. However there was no decrease in sizenoted. On physical examination, there was a 3x3 cm tender, non-movable, hard, bluishpurple lateral neck mass below the preauricular area. On otoscopy, there were cerumen onboth Eustachian tubes. Otherwise, the other ENT findings were normal. The patient was diagnosed to have
Hemangioma
and was referred to a tumor clinic.Hemangiomas are proliferative lesions as compared to AV malformations which are vesselmalformations. Visible lesion on the face or neck may signify presence of another internalhemangioma such as in the oral cavity, larynx or pharynx. Hemangiomas are sometimesassociated with certain syndromes such as Sturge-Weber or posterior fossa lesion in thebrain, arterial lesions in the neck or in the face, cardiac or coarctation problems and eyeabnormalities. Superficially located lesions appear flat and reddish in color. Deep lesions arebluish. Compound lesions such as in this case is both deep and superficial and may appearpurple. Cavernous hemangiomas are compressible, globular, bright red or deep purpleinvolving deep structures. This is the most likely clinical type of hemangioma in this patient.Capillary hemangiomas on the other hand are plaque-like lesions, slightly elevated and moresuperficial. Port-wine stains are capillary type, flat and mostly in the dermis. Strawberrymarks are capillary type with cavernous component.Hemangiomas are usually just observed since they may involute in time. Indicationsfor treatment may include involvement of vital organs, recurrent bleeding, ulceration,crusting or infection and rapid growth and deformity. CT scan is usually warranted but MRImay be needed for deep and large lesions. For small areas not involving the face,intralesional injection with steroids may be done with or without liquid nitrogen cryosurgeryalso with pulsed dye laser. Larger hemangiomas require oral steroids. For lesions that arelife-threatening or non-responsive to steroids Alpha-interferon may be warranted. Carefulsurgical excision may be the last resort which can be very bloody since hemangioma is avascular lesion.
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2. Fernandez, Nancy Contreras 43/F
 This is the case of N.F. 43, female who sought consult for tinnitus of the left ear. 3months prior to consult patient noticed sudden onset of ringing sensation on the left earassociated with dizziness, hearing difficulty and occasional headaches. Otherwise there is noassociated ear discharge, cough or colds. 2 months prior to consult patient consulted in aprivate clinic and was prescribed with Polynerve Vitamins. However, patient noticedpersistence of symptoms. On otoscopy both ET are patent with scanty cerumen and intact TM. Tuning fork test was done with the following results:Weber’s: Lateralization on R earRinne’s: AC>BC R ear; BC>AC L earSchwabach’s: (+) The patient was diagnosed with
Sensorineural Hearing Loss, T/C Meniere’s
andwas advised for PTA, ST and tympanometry. In Sensory Hearing Loss, the pathology mayinvolve the inner and outer hair cells of the Cochlea, hence the transmitted sound wavesdoes not stimulate those structures. HL is usually severe to profound and more so in highfrequency sounds (4,000-8,000 kHz). The clarity of speech sound is usually distorted. Thehearing is worse in the presence of background noise hence understanding speech isimpaired. Etiology may include congenital aplasias of the cochlea, presbyacusis, perilymphfistula, noise-induced, infection or ototoxic drugs such as quinine, aminoglycosides oraspirin or Meniere’s disease. In Neural Hearing loss, the pathology is in the spiral ganglionand CN VIII. There is impaired nerve impulse transmission even if the cochlea is stimulated. There is poorer speech discrimination as compared with sensory hearing loss. It isassociated with very severe hearing loss and tinnitus. The etiology may be an acousticneuroma or vestibular schwannoma. In this case, the etiology of the SNHL is considered tobe Meniere’s disease.Meniere’s disease involves a triad of vertigo, fluctuating hearing loss and tinnitus allof which are present in this patient. It usually occurs in the 3
rd
or 4
th
decade of life (thepatient is 43 years old) It is secondary to distention or increased volume of endolymphaticsystem. There is remission and relapses and with bilateral involvement in 30% of cases. Intreating Meniere’s, the goal is to increase the circulation in the inner ear to decrease thepressure of the lymphatic system. Betahistine HCL may be given as prophylaxis. Diureticssuch as Hydrochlorthiazides and Azetazolamide may be given to reduce the distention.Intratympanic gentamycin may be injected. Methotrexate may be given as immunologictreatment. 
3. Nario, Dennis Asis 25/M
 This is the case of D.N. 25 year old male who consulted for a 10 year history of enlarged tonsils. There is no pain, dysphagia, odynophagia, difficulty sleeping or apnea. Hehas tonsillitis 3x/year in 2 years. On inspection of the oral cavity and pharynx, there areenlarged tonsils, Grade 3. There is no hyperaemia or exudates noted. He was diagnosedwith
Chronic Hypertrophic Tonsillitis
.Human tonsil tissue includes the pair of tonsils at the back of the mouth, theadenoids behind the nose and a final area of soft tissue behind the tongue. Cases of chronic
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